Pubmed Monday

Low-dose spinal anaesthesia for Caesarean section to prevent spinal-induced hypotension.


PURPOSE OF REVIEW: The present review evaluates the evidence available in the literature to see whether low-dose spinal anaesthesia for Caesarean section is effective in preventing maternal hypotension while at the same time guaranteeing effective anaesthetic conditions.

MAIN FINDINGS: From prospective trials, it is clear that lowering the spinal dose improves maternal haemodynamic stability. Doses of intrathecal bupivacaine between 5 and 7 mg are sufficient to provide effective anaesthesia. Complete motor block is, however, seldom achieved and adequate anaesthesia is limited in time.

SUMMARY: Low-dose spinal anaesthesia as part of a combined spinal-epidural technique is a valuable method in improving maternal and fetal outcome during anaesthesia for operative delivery.

Sepsis - What's new in 2019?


PURPOSE OF REVIEW: Sepsis-3 guidelines have implications in a deeper understanding of the biopathology of the disease. Further, the review focuses on timely topics and new literature on fluid resuscitation, the value of steroids in sepsis, and new therapeutic options such as angiotensin II, vitamin C, and thiamine as well as the emerging role of procalcitonin (PCT) in managing antibiotics.

RECENT FINDINGS: Traditional therapies such as type of crystalloid fluid administration and steroid therapy for sepsis are currently under re-evaluation. Angiotensin II is investigated for reversing vasodilatory shock. The role of capillary endothelium leak and cellular metabolism can be affected by vitamin C and thiamine levels. Biomarker level trends, specifically PCT, can aid clinical suspicion of infection.

SUMMARY: Sepsis-3 shifts the focus from a noninfectious inflammatory process and an emphasis on a dysregulated host response to infection. Hyperchloremic crystalloid resuscitation is associated with poor clinical outcomes. Steroid administration can reverse shock physiology; however, mortality benefits remain uncertain. Angiotensin II, vitamin C, and thiamine are novel treatment options that need further validation. PCT assays can help discern between infectious and noninfectious inflammation.

Anesthesia for non-obstetric surgery during pregnancy in a tertiary referral center: a 16-year retrospective, matched case-control, cohort study.


INTRODUCTION: This retrospective, matched case-control cohort study describes the incidence, indications, anesthesia techniques and outcomes of pregnancies complicated by surgery in a single tertiary-referral hospital.

METHODS: Retrospective review of the hospital records of 171 patients who had non-obstetric surgery in the current pregnancy, between 2001 and 2016. Pregnancy outcomes of these women were firstly compared with all contemporary non-exposed patients (n=35 411), and secondly with 684 non-exposed control patients, matched for age, time of delivery and parity.

RESULTS: The incidence of non-obstetric surgery during pregnancy was 0.48%, mostly performed during the second trimester (44%) and under general anesthesia (81%). Intra-abdominal surgery (44%) was the most commonly performed procedure, predominantly using laparoscopy (79%). Women undergoing surgery delivered earlier and more frequently preterm (25% vs. 17%, P=0.018); and birth weight was significantly lower [median (95% CI) 3.16 (3.06 to 3.26) vs. 3.27 (3.22 to 3.32) kg, P=0.044]. When surgery was performed under general anesthesia, low birth weight was more frequent (22% vs. 6%, P=0.046). Overall pregnancy outcomes were neither influenced by trimester nor location (intra- vs. extra-abdominal) of surgery. However, preterm birth rate secondary to surgery was higher for interventions during the third trimester, compared with other trimesters (10% vs. 0, P <0.001).

CONCLUSION: Pregnant women who underwent surgery delivered preterm more frequently and their babies had lower birth weights. Laparoscopic surgery did not increase the incidence of adverse pregnancy outcomes. General anesthesia was associated with low birth weight. Whether these associations suggest causation or reflect the severity of the underlying condition remains speculative.

Detection of Brain Activation in Unresponsive Patients with Acute Brain Injury.


BACKGROUND: Brain activation in response to spoken motor commands can be detected by electroencephalography (EEG) in clinically unresponsive patients. The prevalence and prognostic importance of a dissociation between commanded motor behavior and brain activation in the first few days after brain injury are not well understood.

METHODS: We studied a prospective, consecutive series of patients in a single intensive care unit who had acute brain injury from a variety of causes and who were unresponsive to spoken commands, including some patients with the ability to localize painful stimuli or to fixate on or track visual stimuli. Machine learning was applied to EEG recordings to detect brain activation in response to commands that patients move their hands. The functional outcome at 12 months was determined with the Glasgow Outcome Scale-Extended (GOS-E; levels range from 1 to 8, with higher levels indicating better outcomes).

RESULTS: A total of 16 of 104 unresponsive patients (15%) had brain activation detected by EEG at a median of 4 days after injury. The condition in 8 of these 16 patients (50%) and in 23 of 88 patients (26%) without brain activation improved such that they were able to follow commands before discharge. At 12 months, 7 of 16 patients (44%) with brain activation and 12 of 84 patients (14%) without brain activation had a GOS-E level of 4 or higher, denoting the ability to function independently for 8 hours (odds ratio, 4.6; 95% confidence interval, 1.2 to 17.1).

CONCLUSIONS: A dissociation between the absence of behavioral responses to motor commands and the evidence of brain activation in response to these commands in EEG recordings was found in 15% of patients in a consecutive series of patients with acute brain injury.

Pain management after laparoscopic hysterectomy: systematic review of literature and PROSPECT recommendations.


BACKGROUND AND OBJECTIVES: Laparoscopic hysterectomy is increasingly performed because it is associated with less postoperative pain and earlier recovery as compared with open abdominal hysterectomy. The aim of this systematic review was to evaluate the available literature regarding the management of pain after laparoscopic hysterectomy.
Randomized controlled trials evaluating postoperative pain after laparoscopic hysterectomy published between January 1996 and May 2018 were retrieved, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, from the EMBASE and MEDLINE databases and the Cochrane Register of Controlled Trials. Efficacy and adverse effects of analgesic techniques were assessed.
Of the 281 studies initially identified, 56 were included. Of these, 31 assessed analgesic or anesthetic interventions and 25 assessed surgical interventions. Acetaminophen, non-steroidal anti-inflammatory drugs, and dexamethasone reduced opioid consumption. Limited evidence hindered recommendations on alpha-2-agonists. Inconsistent evidence was found in the studies investigating pregabalin and transversus abdominis plane block, and no evidence was found for intraperitoneal local anesthetics, port site infiltration, or single-port laparoscopy. Measures to lower peritoneal insufflation pressure or humidify or heat insufflated gas seem to reduce the incidence of shoulder pain, but not abdominal pain.
The baseline analgesic regimen for laparoscopic hysterectomy should include acetaminophen, a non-steroidal anti-inflammatory drug, dexamethasone, and opioids as rescue analgesics.

The DIFFMASK score for predicting difficult facemask ventilation: a cohort study of 46,804 patients.


Facemask ventilation is an essential part of airway management. Correctly predicting difficulties in facemask ventilation may reduce the risk of morbidity and mortality among patients at risk. We aimed to develop and evaluate a weighted risk score for predicting difficult facemask ventilation during anaesthesia. We analysed a cohort of 46,804 adult patients who were assessed pre-operatively airway for 13 predictors of difficult airway management and subsequently underwent facemask ventilation during general anaesthesia. We developed the Difficult Facemask (DIFFMASK) score in two consecutive steps: first, a multivariate regression analysis was performed; and second, the regression coefficients of the adjusted regression model were converted into a clinically applicable weighted point score. The predictive accuracy of the DIFFMASK score was evaluated by assessment of receiver operating characteristic curves. The prevalence of difficult facemask ventilation was 1.06% (95%CI 0.97-1.16). Following conversion of regression coefficients into 0, 1, 2 or 3 points, the cumulated DIFFMASK score ranged from 0 to 18 points and the area under the receiver operating characteristic curve was 0.82. The Youden index indicated a sum score ≥ 5 as an optimal cut-off value for prediction of difficult facemask ventilation giving a sensitivity of 85% and specificity of 59%. The DIFFMASK score indicated that a score of 6-10 points represents a population of patients who may require heightened attention when facemask ventilation is planned, compared with those patients who are obviously at a high- or low risk of difficulties. The DIFFMASK score may be useful in a clinical context but external, prospective validation is needed.

Interscalene versus supraclavicular plexus block for the prevention of postoperative pain after shoulder surgery: A systematic review and meta-analysis.


BACKGROUND: Interscalene brachial plexus blockade is the most common regional anaesthesia technique for alleviating pain after shoulder surgery, but complications occur, including ipsilateral hemidiaphragmatic paresis, Horner's syndrome and hoarseness. The supraclavicular approach might be an effective alternative with fewer adverse effects.
OBJECTIVES: The aim of this study was to determine whether there is a difference in postoperative pain scores and morphine equivalents between interscalene and supraclavicular brachial plexus blocks. Secondary endpoints were serious adverse events.
DESIGN: A systematic review and meta-analysis of randomised controlled trials.
DATA SOURCES: A comprehensive literature search of Embase, CENTRAL, MEDLINE and Web of Science was performed from the earliest record to December 2018. ELIGIBILITY CRITERIA: Prospective randomised controlled trials that compare interscalene and supraclavicular brachial plexus blocks in patients undergoing shoulder surgery were eligible for inclusion. Only studies that reported their methods transparently and comprehensibly were included. Conference abstracts or meeting abstracts were not excluded a priori. Risk of bias was assessed using Cochrane methodology.
RESULTS: Twelve studies were eligible for meta-analysis. The supraclavicular approach showed overall comparable 24-h pain scores (mean difference -0.34; 95% CI -0.75 to 0.07, P = 0.11) and comparable morphine equivalent consumption (mean difference 1.84 mg per 24 h; 95% CI -0.00 to 3.69, P = 0.05). Secondary endpoint analysis revealed a significantly lower rate of hemidiaphragmatic paresis (risk ratio 0.56; 95% CI 0.39 to 0.82, P = 0.003) and Horner's syndrome (risk ratio 0.29; 95% CI 0.19 to 0.44, P < 0.00001) for the supraclavicular approach. There was no significant difference in hoarseness (risk ratio 0.73; 95% CI 0.48 to 1.13, P = 0.16).
CONCLUSION: After 24 postoperative hours, pain scores and consumption of morphine equivalents were comparable. Adverse effects were less common with the supraclavicular approach. The supraclavicular approach might be an efficient alternative to the interscalene approach for shoulder surgery. However, the available evidence is inadequate and prevents a firm conclusion.

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